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These are heady days to be a nurse. With a two-year-old mandate from the Institute of Medicine calling for us to practice at the highest level of our profession, achieve independence from physician oversight as we diagnose, prescribe, and treat sick patients, and care for patients with increasingly complex cases, nurses are poised like never before to continue their march toward the center of health care delivery.

It’s high time. More and more of us are turning to nurse practitioners for our primary care. And it’s not just because they’re easier to get appointments with (they are), spend dramatically more time with patients (they do), have much of the same prescriptive powers as physicians (though not, as yet, in Virginia). It’s not even because they get excellent training as healthcare generalists or that advanced practice nurses, like NPs, are everywhere, with some 9,000 new ones graduating each year and joining the ranks of the nation’s roughly 140,000.

It’s because the care that advanced practice nurses give– at physician-led offices, minute clinics, rural health care centers, and bustling urban hospitals– is second to none.

As gatekeepers of health, advanced practice nurses (those with at least a master’s or doctoral degree) are the perfect answer to our 21st century health care woes. With a well-documented drop in the numbers of American family practitioners– fewer than one in five physicians-in-training opt to be family practitioners– nurses stand ready to fill in the gap.

First, there’s the cost differential, critical to any discussion about health care delivery. In a physician practice, research has shown that nurse practitioners decrease the cost per patient visit by as much as a third. NPs typically earn less than physicians– about half of physicians’ $198,000 average annual salary– and are less costly to educate, as well.

Second, there is a boom in interest in nursing, which, if cultivated properly, will ultimately translate into an increase in access. People want health care that’s convenient, not cumbersome. We don’t have time to wait four weeks for an appointment, linger 45 minutes in the lobby, thumbing through tattered magazines, hoping for an old, outdated system to heal us. In a 24/7 world, health care must strive to become more immediate and accessible, or– like people scrolling through a web page, stepping into a store or flipping through a catalog– we’ll lose the opportunity to treat them.

And losing patients means, quite practically, that we lose a very basic opportunity to keep people well. Unaddressed health problems escalate. They grow exponentially more expensive. It’s why a cavity can blossom into an abscess, and, ultimately, cause blood poisoning. Why unchecked diabetes may lead to amputation. Why unchecked high blood pressure spurs strokes. But it doesn’t have to be that way.

Already, there is evidence that many are turning to nurse practitioner programs as a way to stabilize and safeguard their employment futures. More mid-career men and women are applying to our programs than ever before– our applications are up 13 percent in a year, and more than 25 percent in the last five years– and our waiting list grows.

By swelling the ranks of all levels of nursing students, places like UVA have the opportunity to change the face of primary care, putting nurses, not physicians, at the forefront. We must continue to fortify our investment in these people: expanding nurse practitioner training programs, finding and training more nurse faculty, encouraging bachelor’s and master’s level nurses to complete their terminal degree, even offering loan forgiveness for those who promise to work for several years in public service.

We also need to widen NPs ability to act independent of a physician’s oversight here in Virginia, as is the case in so many other states, so they can do as the 2010 Institute of Medicine report recommends: practice to the fullest extent of their training.

Even absent the Supreme Court’s landmark decision, these are powerful changes that are moving at lightning speed. Nothing in health care is getting less complex. But this pivot toward nurses as gatekeepers of health and bastions of preventative care will have a powerful effect on the health and wellness of our population. If nurses are the link between people receiving care, or not, let all of them stand tall. I’m proud to stand right beside them.~Author Dorrie Fontaine is the dean of the UVA School of Nursing.

@ A Concerned Citizen and @ No: Your ignorance is showing. Before sounding off it might be wise to get educated yourself. Next time you end up in the Emergency Department you may thank God you had a Nurse Practitioner tending to you. And next time you have brain surgery you will bless the Nurse Practitioner who works hand in hand with the neurosurgeon. Why do you think a surgeon, or any physician, works with Nurse Practitioners as full partners and that Nurse Practitioners submit charges just like a physician? Why do you think nurse practitioners write prescriptions? Because they are uneducated? I do hope you have the chance to be cared for by a Nurse Practitioner so you can let us know that your life was changed for the better or moreover, was saved.

Thank your lucky stars July 1st, 2012 | 9:40pm

Sorry for the typos.

JB July 2nd, 2012 | 9:43am

Nurse Practitioners can handle much of the healthcare load at a fraction of the cost. Doctor billing rates are incredibly high. For many issues, you don't need a doctor, and this is where Nurse Practitioners are a huge help.

We're undeniably moving towards rationed care, and this will help save all Americans a ton of health care costs.

ontheroad33 July 2nd, 2012 | 11:16am

I would expect a large % of primary care is just referral anyway.

A Concerned Citizen July 2nd, 2012 | 7:50pm

Nurses were weeded out of medical school long ago. If you want a dumb doctor, go to a nurse. If you want your doctor to miss things (even more than real doctors, since everyone is human I'll assume that everyone misses something), then go to a nurse.

I think a nurse works with a surgeon because nurses are cheaper than doctors. Nurses submit charges because institutions bill as much as possible to make ends meet (woe to the poor chap who doesn't have health insurance and can least afford the full bill). Nurses practitioners write prescriptions due to desperation in the system to find enough care providers, especially in underserved areas--certainly not because nurses are equally qualified, trained, or experienced. Many medical issues don't require a doctor and "just a nurse" will suffice, except when you do need a doctor, and you better hope the relatively poorly trained nurse knows when that is--the nurse who didn't go to medical school, didn't do internship, didn't go to residency, and obviously didn't go to fellowship.

Here's how I predict this will play out: NPs will garner increased responsibilities. They will take on a greater role in the primary care arena. They will further overburden specialists because all patients will be referred for most basic illnesses, such as diabetes and chronic kidney disease, but that's okay because that trend will shunt more doctors into specialties and further exacerbate the desperate need for primary care providers. But here's the kicker: nurses are selfish actors as much as anyone else and will soon spurn the rural and underserved areas they used as leverage to get more responsibilities and higher pay, because they'll earn more in large cities and institutions, just like everyone else in this creaking, crumbling system.

For all the vitriol above, I actually think nurses play a very important role, but not in assuming the role of the physician.

Kristin July 3rd, 2012 | 4:38am

As usual, Dorrie Fontaine delivers the truth in a simple and classy manner. I was profoundly lucky to have been a student at UVa SON when she was the new Dean. She was immediately known to be progressive, forward-looking, innovative, and ultimately elegant and kind. I'm now halfway through a DNP/FNP, and will consider myself a success when I recognize her in my work! Wa-Hoo-Wa!

Thank your lucky stars July 3rd, 2012 | 9:06am

@ Kristin: Fabulous. Congratulations on your upcoming degree. I too am very impressed with Dorrie Fontaine. She's smart, personable, thoughtful and sincere. She is a marvelous role model for nurses and all hospital employees. We are so lucky to have her here. Her rally talk on the steps of the Rotunda in support of President Sullivan was absolutely dynamite.

ACNP-BC July 3rd, 2012 | 10:40am

As a Nurse Practitioner I find this comments about being “dumb” or “poorly educated” quite insulting.

It is appearant that you are NOT knowledgeable regarding the in depth training and education nurse practitioners must endure. Furthermore, you have not taken the time to look up what educational requirements are embedded in the NP education. I challenge you to become more informed before spouting off in a article blog about a profession.

Secondly, Nurse Practitioner outcomes for patients are equal to physician outcomes for patients time and time again. I introduce you to the following Peer Reviewed Scholarly Research articles for you to become informed:

Published in the American Journal of Critical Care:
->Outcomes of Care Managed by an Acute Care Nurse Practitioner/Attending Physician Team in a Subacute Medical Intensive Care Unit.
Am J Crit Care March 2005 vol. 14 no. 2 121-130

And just to be sure you understand, this article was written in 1974 in the NEW ENGLAND JOURNAL OF MEDICINE which dates back to how long NPs have been providing competent, safe and cost effective care:
->The Burlington Randomized Trial of the Nurse Practitioner. N Engl J Med 1974; 290:251-256. January 31, 1974.

There are hundreds of scientific articles which provide validity for safe, competent, and cost effective NP healthcare.

Nurse Practitioners are more than competent to handle primary care issues including diabetes and hypertension. In addition to Family Nurse Practitioners, there are Psychiatric, Women’s Health, Gerontology, Pediatric and Acute Care Nurse Practitioners. Yes we are specialized to care for the entire spectrum of patient healthcare needs. From birth to critical care emergent management, we do it ALL!

So the next time you decide NPs are not knowledgeable do your homework!

John G. Brenner July 3rd, 2012 | 12:38pm

Great piece, I have no doubt that the quality of care from FNP's (NP) is second to none. I know many fine APRN's, DO's, PA's, and MD's, and a few poor ones. Choice is a good thing!

John G Brenner MS MSN APRN

AWESOME FNP July 3rd, 2012 | 1:03pm

AMEN! ACNP-BC & Thank your lucky stars
This "concerned citizen" sound very educated. Granted I too am a Nurse Practitioner and love it, but I have run up against people like this before. Typically, they are physicians who feel threatened by mid-level providers. If you notice in his/her ranting nothing is ever mentioned about PA's who are overseen by the medical board, whereas, we are governed by the nursing board. Obviously there is a major issue with nurses of all kinds, not just practitioners.

So Concerned Citizen it sounds like to me that you have a major issue with Nurse Practitioners. So I hope & pray that if you ever need the healthcare that we have to offer in this country that you have the luxury to request a "real doctor".

Kristin July 3rd, 2012 | 1:15pm

Concerned Citizen is obviously someone who did or should fail out of medical school, or doesn't work in the medical profession at all. There's a thing called evidence. Absolutely none can be produced saying NP care is inferior to that provided by an MD. Carry on without Uneducated Citizen, guys.

Kristin July 3rd, 2012 | 1:17pm

And no, they don't cost les to educate bc of any other reason than that doctors with your attitude made medicine a good old boys club. The majority of those idiots are bein phased out, thank god.

AWESOME FNP July 3rd, 2012 | 1:25pm

You are so right Kristin. Most of the docs I work with would rather have NPs so the don't have to see the new patients and they can leave for the early tee time. Which doesn't bother me a bit cause I have my time.

Alaska FNP July 4th, 2012 | 1:02am

Whoa dude-time out! My knee jerk reaction is that you are speaking out of a hole, not your mouth. ROFL. The part that made me want to scream is that "primary care" is ..."mostly referrals" to treat chronic medical conditions. It's possible you are not stupid but you are clearly uninformed and are carrying some kind of grudge against nurses (women?). Número UNO, what in the world do you think primary care means? Do you know? It's the medical home model of the future and you DEFINITELY will have your diabetes, HTN, COPD/asthma, BPH, many psychiatric problems, prenatal care, heart disease treated in primary care & increasingly by midlevels, although NPs are better trained for this - PAs trained for physicians is highly procedural. If an NP is graduated from either a masters or doctoral program, they won't make it in primary care setting if they DON'T know how to manage chronic health problems. I definitely give equally competent care to my patients as they would receive from a doctor- have often been told patients after they have been seen by me that they've never had things such good care. Good luck with that bitterness thing. Could be reflux- go see an NP, quick! ;-)

NP Advocate July 4th, 2012 | 2:29am

@ concern citizen BITTERNESS! ! Get yourself educated!

JB July 4th, 2012 | 10:18am

"A Concerned Citizen July 2nd, 2012 | 8:50pm

Nurses were weeded out of medical school long ago. If you want a dumb doctor, go to a nurse. "

What's the difference between a Nurse Practitioner and a doctor? A different educational path, a lot of ego, and a significantly larger cost.

The first clear sign that someone is a clown is when they make vitriolic comments about something they clearly know nothing about. Nurse Practitioners work under the supervision of doctors, and are plenty capable of handling much of the health care workload.

Part of universal coverage is more efficient and less costly dispensation of care.

Medical Student July 5th, 2012 | 2:59pm

If I knew that I could be a nurse and work independently doing all the same things as a doctor, I don't think I would have gone to U.Va for 4 years and then 4 years to medical school with another minimum of 3 years of Residency training when I could have gone the easy route and been a nurse practitioner and confuse people when I introduce myself as Dr. So and So your nurse practitioner.

ACNP-BC July 5th, 2012 | 4:45pm

@Medical Student

Hmm, I would have to disagree that the road to becoming a Nurse Practitioner is easy by any mention of the word. In my case, it was a very hard and challenging road to get to this position.

As in your field, we have also completed 4 years to obtain our Bachelors. In addition during this time we are actually performing hands on clinical skills in assessment, lab interpretation and patient/provider relationship. In addition we must be thoroughly knowledgeable in Medications as we are actually giving them to our patient. So we must be well versed in the medication’s mechanisms of action, side effects and adverse reactions to intervene immediately. We see first hand what flash pulmonary edema looks like, or the real time effects of dopamine on blood pressure and heart rate or adjusting Intra-Aortic Balloon Pump settings, or CRRT settings based upon the patient’s condition. What I am explaining here is EXPERIENCE and CRITICAL THINKING. You can’t teach EXPERIENCE and CRITICAL THNKING. As a nurse experience and critical thinking are well developed long before we pursue our higher education. Most Registered Nurses work during their degree attainment, which further adds to their inept ability to provide patient care. Secondly, in addition to understanding the medical pathophysiology/diagnosis for the patient we as nurses must always be assessing for spiritual, emotion, mental and cognitive deficits. We provide holistic care to the entire spectrum of human needs, “Holistic Care”.

Our per se “residency” experience is gained during work as an RN. Hands on clinical experience.

Some NP programs are two years or three years depending on the higher education degree pursued.

In our NP programs we are specifically specialized to provide care to a specific patient population, more so a “Fellowship”. I would say that is where the MD and NP differ. MD can do any type of practice. NPs don't want to be MDs. We prefer being experts in our fields of specialty, not have limited general knowledge in all areas of practice.

It is my understanding that generally MDs attain 16,000 hours of clinical time while in school. RNs who work full time will have this requirement met before they apply to schools for NP.

As far as the Doctorate degree is concerned, I find it interesting that you assume the title “Doctor” is only for MDs. I believe the educators at UVA have secured PhDs and we call them Dr. So and So, right? Physical Therapists and Pharmacist obtain their Doctorates, correct? Engineers obtain their Doctorates, correct? This title is not limited to your field only.

Lastly, I would caution you to understand that you will at some point in time be working with Nurses and NPs. You may want to respect what our field brings to patient care, as we are all in this together for the Patient- not against each other.

Medical Student July 5th, 2012 | 6:55pm

Thanks for the reply, me, the Interns and Residents got a lot of good comical relief from it, wheeew, wipes away tears.

Kristin July 5th, 2012 | 7:09pm

Medical student - I'd be crying too if I went to school for ten times the amount of money learning exactly the same thing just so I could join a Good Ol Boys club.

Seriously, though, there is a place for all of us. MDs should be specialized, they shouldn't in primary or family care. It is a waste of money. If you want to go into primary care, be an NP. If you want to have a specialty, like cardiology or surgery or something, be an MD. That's how we should all be thinking. There is a lot I can do that an MD can't, and I can do nothing that a surgeon does.

Also, Medical Student, be careful. It is in medical school that you are supposed to be learning about the different roles and scope of practice of your peers. Laughing at nurses to the point of tears is going to get you not only kicked out of school (especially if you are at UVA), it will get you no where fast when you get into the real world. I and the other nurses on this message chain have FAR more wisdom and experience than you do right now. You would do best to learn from it, and your career will benefit too. I won't laugh at you when you graduate and I have to hold your hand for you to do anything, which I promise you will be the case when you are a first year resident, because I do it every day right now. That said, I understand you are a medical student and are very young. I am sure you will get caught up as you move closer to being a resident.

JB July 6th, 2012 | 3:12pm

Kristen,

Well said. We pay way too much for egos in the medical profession, when what we really need is efficient and effective care.

Gay Lynn July 7th, 2012 | 10:02am

@ Medical Student
I do not know about my peers, as for myself, I have NEVER introduced myself as "doctor". As a matter of fact, when my patients do refer to me as "doctor", I very quickly correct them. I explain "I'm not a doctor- I work for a living". For the record, when I began practicing as a APRN-CNP a few years ago, the patients I saw would often times request to see the doctor. However, after the doctor repeatedly decided to go golfing, or take a spur of the moment vacation those same patients were seeing me. NOW, those same patients are requesting to see me because I "listen" and take the time to explain lab tests, etc. They initially act surprise when I ask ROS questions- I exain that I'm just helping them recall if there was an problems or concerns that they were wanting to discuss with their next office visit. They have also made comments that the doctor had never explained what the various lab results meant.
I find it rather sad that the medical field attempts to keep the general population in "awe" of it's knowledge and workings. Kind of like they are concerned that patients are catching on that NPs are competent to provide primary care- cheaper, and often holistically better than they can- maybe because we do take the time to listen and are interested in what is going on in our patients lives. We include our patients in the plan of care- empowering them if you will to active participants in their own health... Not simply "do this, take this... because I'm the doctor and said so "!

JB July 7th, 2012 | 10:17am

I for one am looking forward to increasing the role of Nurse Practitioners as a more cost effective solution to the provision of health care. It's time for health care to get more professional, and less egotistical. Honestly, we're a bit too much in awe of doctors, and we can't afford the health care system that has evolved. Doctors are just people with a number of years of med school. Their education is a good thing, but doesn't make them infallible.

JSSNP July 7th, 2012 | 11:48am

@Medical Student: You make me very sad. I have been an NP and NP educator for the last 20-25 years of my 42 year nursing career. Consider the following:
1) Enlightened physicians see the value of NPs and other advanced practice RNs. Not all consider NPs a threat or some form of incompetent medical school dropout or inferior physician-wannabe as you suggest...See the following: http://www.jfponline.com/Pages.asp?AID=9173
2) Multidisciplinary authors, including a well-respected Hopkins experts, a professor of medicine (physician)and 2 professors of public health, concluded after a rigorous systematic review of 18 years of NP literature, that NP patient outcomes are the same or better than physician patient outcomes in comparable situations. The practice restrictions placed on NPs by organized medicine in the name of patient safety are not evidence-based. Rather they are based on money, power and fear, and they limit patients' access to much-needed health care.
3). MD-NP roles often do overlap, but NPs are NOT EVER taught that their role is 100% interchangeable with the MD role. Both roles compliment other. Some physicians even choose an NP to provide their own health care. Yes, I have had physicians choose me to provide care for themselves or family members. The reality is that MDs and NPs generally work very well together on the front lines of everyday practice.
4) The number of NPs is predicted to nearly DOUBLE by 2025: http://www.amaassn.org/amednews/2012/07/02/bisb0702.htm - So chances are you WILL have to interact with NPs. I hope you do so in a way that benefits your patients.
5) Finally, no one type of health care provider is all-knowing. A good provider (MD, NP, PA, PT, RD, etc.) recognizes their limitations as well as their expertise.....As you progress through your medical education, I hope you will lose your arrogance and come to appreciate the contributions of all members of the health care team. Much needs to be done to turn around our chronic disease epidemic and to care for our aging population. Patient outcomes are known to improve when the health care team works together.

This is why I do not go to the doctors. It's a joke to me and a waste of
my time.

JB July 8th, 2012 | 11:18am

"Here is the article supporting point #2 in my last post:
www.nursingeconomics.net/ce/2013/article3001021.pdf"

People "like" the idea of going to a doctor, but since the research shows that the results aren't even better, why pay the significant premium? In fact, NPs are generally acknowledged to be more perceptive about patient needs than doctors.

Sadly, part of Med School seems to be training docs not to be in touch. They almost need another year of training to erase some of the things they learn there.

Hook Reader July 11th, 2012 | 3:55am

@Kristin: "There is a lot I can do that an MD can't, and I can do nothing that a surgeon does." Example(s) please.